Healthcare Provider Details

I. General information

NPI: 1497904221
Provider Name (Legal Business Name): MIRTA RICE PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N COMMERCE PKWY SUITE NUMBER 200
WESTON FL
33326-3216
US

IV. Provider business mailing address

1625 N COMMERCE PKWY SUITE # 200
WESTON FL
33326-3216
US

V. Phone/Fax

Practice location:
  • Phone: 954-385-0353
  • Fax: 954-389-0886
Mailing address:
  • Phone: 954-385-0353
  • Fax: 954-389-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. MIRTA RICE
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 954-385-0353